Compelling commentary on children's health

The children’s nutrition market in the U.S. is heating up
with Nestle’s introduction of the probiotic Lactobacillus reuteri into their
new pediatric formula, Boost Kid Essentials.Actually the probiotic isn’t in the formula but in the straw
that’s poked into the drink container.With the first sip your child gets 100 million reuteri organisms.Genius.The straw isn’t new, however.It’s been in use for years in Europe – a patented product of
Biogaia AB of Sweden.I posted on
it a year and a half ago and wondered who in the States would be smart enough
to pick up on it.Now we know.

Nestle appears to have the insight to recognize the critical
importance of intestinal microflora in children’s health.More importantly, they’re pioneering
products that allow reliable delivery of study-proven probiotic bugs to the
intestinal tract of our youngest patients.

So how important are bugs to kids?Perhaps the better question to ask is, “How important is
reuteri to kids?” And why would a product like Boost Kid Essentials offer an
advantage to kids who need caloric supplementation?Here are some of the proven benefits of reuteri in kids
(Your mileage, of course, may vary):

Fewer sick days.In a recent study, 181 adult factory
employees were assigned to receive a daily supplement containing either reuteri
or a placebo.The employees were
followed over 80 days and the group taking the reuteri was found to have a 55%
reduction in illness when compared with the placebo group. While this study didn't look at kids, we may be able
to extrapolate the effect to children.

Less diarrhea.A 2005 study compared children in
daycare centers supplemented with reuteri against those without.The children supplemented with reuteri
experienced fewer and shorter episodes of diarrhea.The duration of rotavirus diarrhea in hospitalized babies
has been shown to be diminished in the presence of reuteri.

Inhibits the growth
of numerous nasty organisms.L. reuteri releases a natural inhibitor of bad organisms called
reuterin.And in the test tube
this has been shown to prevent the growth of salmonella, shigella, strep, E.
coli and the ulcer bug, H. pylori among others.

And that’s not all.Reuteri is one of the only probiotic
organisms found to colonize nearly the entire length of the intestinal tract,
not just the colon.It’s also been
identified in breast milk.And
while we would never use a product like Boost Kid Essentials in a baby, it is
reuteri that was found last year to have such dramatic effects at minimizing
misery in screaming babies (“colic” if you’ll pardon the term).And subsequent studies in preemies have
found dramatic effects on upper intestinal motility.Whew! Difficult to explain, perhaps, but nonetheless fascinating.But it just shows that our studies in probiotic use in
children are raising as many questions as they answer.

As you can tell, I love reuteri.

Stay tuned.The
pediatric probiotic market is just picking up and I wouldn’t be surprised if
Nestle had a few more tricks up its sleeve.

For the average consumer the probiotic marketplace can be tough to negotiate. What’s real, what works and how do probiotics do what they do. If you’re looking for a remarkably well-written primer on probiotics be sure to check out The Probiotics Revolution - The Definitive Guide to Safe, Natural Health Solutions Using Probiotic and Prebiotic Foods and Supplements (Bantam 2008) by Dr. Gary Huffnagle and Sarah Wernick.

The Probiotics Revolution does a great job of taking complicated gut immunology and simplifying it for the average reader. This book will please the patient looking for guidance on bugs and dosing as well as the doctors and providers looking for a basic evidence-based approach to this evolving corner of complementary medicine. And they name names – products and doses, even for kids. Dr. Huffnagle also offers the story of his personal probiotic epiphany which makes the whole book believable and approachable.

I recommend this book at all probiotic presentations I give as well as to parents looking be thoroughly educated in the use of probiotics. And if you’re still curious at the end you can dig up the original articles that are referenced throughout the book.

“Dr. V, what probiotic should I give my child?” I hear this every day and each time I remind my parents that the use of any probiotic needs to be tailored to the need of a child. Just like specific antibiotics have to be taken for particular infections, specific probiotic bugs need to be taken with particular problems in mind. Here are a few that I regularly recommend. These bugs that have been proven in a variety of studies to be clinically effective at treating specific conditions:

Lactobacillus reuteri. Affectionately known as ‘reuteri’, I think of this as a sleeper among probiotics. You tend not to hear much about it but it’s one of the most powerful bugs available. Recent studies have demonstrated effects ranging from the cure for infant misery to the prevention of diarrhea in daycare centers. I see reuteri as one of the best preventive bugs for kids. Available exclusively through Biogaia of Sweden as chewable tablets, chewing gum or via (I love this) reuteri impregnated juice box straws.

Lactobacillus GG. To those in the know, it’s ‘GG’. This is perhaps one of the most thoroughly studied probiotics in children with effects claimed in everything from eczema to asthma. Like reuteri, I like GG as a prophylactic or preventative bug. Culturelle offers a reputable product and it’s widely available in retail outlets. Offer one capsule, or 10 billion bugs, per day sprinkled in baby food or apple sauce. Look for GG to appear in select infant formulas in the next couple of years.

Bifidobacterium lactis. If you look at the colonic inhabitants of the typical breastfed infant you’ll find mostly bifidobacteria. In fact, it’s been suggested that this abundance of bifidobacteria accounts for the remarkable health enjoyed by breastfed babes. Bifidobacteria as a probiotic has been shown to prevent infectious diarrhea, shorten the course of infectious diarrhea once its taken hold, and decrease the shedding of rotavirus. B. lactis has been shown to increase the production of secretory IgA (one of the first lines of defense) in the intestinal tract which is always a good thing. Look for B lactis in Nestle’s Good Start with Natural Cultures.

Sarcomyces boulardii. This is the only probiotic on the list that isn’t a bacterium but rather a yeast. S. boulardii is best known for it’s effects in reversing the diarrhea often experienced during antibiotic use, and specifically against the infection Clostridium difficile. Personally in my clinic I have used this to combat toddler’s diarrhea with some success. Available as Florastor sachets, 1 packet or 5 billion bugs per day.

As probiotics represent a practically unregulated industry remember that what you read on a manufacturers label may not be what you’re putting into your child’s mouth. Stick with reputable brands as I have suggested.

This weekend I addressed the Malaysian Pediatric Association Annual Congresson probiotic use in children. As it turns out, many of them could have stood up and given the same talk. It turns out that the use of probiotics has been way of life for pediatricians in southeast Asia for some time. My appearance was a reality check on the subtle sense entitlement that American physicians often harbor. I was also privileged to judge the meeting’s poster case presentations which consisted of strange and unusual disease seen in only this steamy corner of the world. And I thought I worked hard.

I might suggest that the American Academy of Pediatrics fly in a handful of hardworking general pediatricians from Malaysia. While none of us in the U.S. would like to admit it, we would definitely learn something.

A class action lawsuit filed this week in California claims that Dannon has mislead all of us by claiming that its yogurt Acitiva helps regulate the digestive system. Perhaps I’ve missed something. Bifidobacterium regularis, the bug found in Activia, has been proven to exert a number of dramatic effects on the intestinal tract including improved transit time (makes things move better) as well as protection of the gut from colonization by harmful bacteria. For a great (but technical) review of what B. regularis can do, check out this recent review.

It’s important to understand that different yogurts contain different bugs that do different things. Each is unique in its effect on the body. While food manufacturers are prohibited from making specific health claims on their labeling (that would make them drugs), it would seem that from a pediatrician’s perspective, Dannon has been sufficiently neutral in their claims. Too bad it's come to this.

Lawyers aside, talk to your pediatrician and ask about the use of real yogurt in you child beginning late in her first year of life. Beyond Dannon's Activia, I like Stoneyfield Farms and their pet, Lactobacillus reuteri. If you recall, this is the same critter used in last year's screaming baby study. It's a small world.

This is amazing: It seems how babies are born can impact their immune system. When compared with their nursery mates born by vaginal delivery, babies born by C-section appear to be at increased risk for food allergy.

But how can this be? How could the type of delivery affect risk for something like allergy to eggs? As it turns out, babies entering the world via mommy’s bottom are exposed to a variety of organisms that immediately begin to colonize and grow in the intestinal tract. Those born by C-section on the other hand are denied this apparently critical early bug exposure. Intestinal bacteria are critical in helping prepare the newborn immune system for what lies ahead. The immunology is dicey but suffice it to say it’s amazing and definitely not intuitive.

Could rising allergy rates be related to the popularity of the Cesarean delivery? Perhaps if you believe the hygiene hypothesis. This theory suggests that a lower exposure in early childhood to bacteria and other antigens in developed countries has led to inadequate development of immune responses with a resulting epidemic in allergy and asthma.

Now this is remarkable. Biogaia of Sweden has developed a juice box straw that contains a dose of reuteri probiotic. It seems they’ve got patented technology that keeps a mini bolus of Lactobacillus reuteri suspended in the middle of the straw. When junior takes his first suck, in go 100 million viable organisms. So what? As it turns out reuteri has been shown to play a role in the prevention of diarrhea as well as decreasing the duration of diarrhea episodes in daycare centers. While the straw can’t be used for an infant, it’s Biogaia’s reuteri that that created the stir with the colic study recently published in Pediatrics.

While probiotic delivery typically doesn’t represent a major challenge with toddlers, this is an innovative way to deliver a viable, clinically efficacious probiotic.

As far as I’m aware, this hasn’t been picked up by any of the major juice manufacturers. For better or for worse, I’m thinkin’ these guys are way ahead of the curve.

The buzz in the nursery is that Nestle is about to release the American market’s first FDA approved probiotic-supplemented infant formula, Good Start Supreme with Natural Cultures. Their pet bug is Bifidobacterium lactis which is the predominant organism found in the intestinal tract of breast-fed babies. It’s felt that much of the breast-fed baby’s wellness is tied to this population of colonic critters. B. lactis is known to help with the synthesis of vitamins B & K as well as improve the absorption of other minerals. Immune enhancing benefits including improved release of IgA in the intestinal tract and suppression of intestinal pathogens are among its attributes.

While most parents are open to probiotic use in children, their use in infancy is new territory. Safety shouldn’t be a concern in this case given its 15 year track record in 30 countries. Nestle will, however, have to prove to pediatricians and mothers that their brew offers tangible benefits to babies. And while probiotics may represent a natural option for intestinal health, most parents have little understanding of what probiotics do and their real benefits. Education of both new mothers and even pediatricians will be required before probiotic supplemented foods are recognized as having real value.

Despite the fact that some innovations in infant nutrition are market driven, probiotics represent the next frontier for pediatric neutraceuticals. In fact, Nestle may do for probiotics what Mead Johnson’s Lipil did for DHA & ARA.

Available only in powder form, this new formula is said to come into the market at about $1.50 more per can over regular Good Start. And by the way, don’t toast this one in the microwave. In fact don’t prepare it with water warmer than body temperature. Bugs can’t take the heat.

It’s a timeless question when it comes to the miserable baby: Is it the brain or the gut? Recent indications are that the gut and its many bacterial inhabitants may hold a clue.

A study published last month in the journal Pediatrics looked at the use of probiotics in the treatment of unexplained irritability in breast fed infants. Researchers treated one group of miserable babies with the probiotic Lactobacillus reuteri and another group with simethicone, the active ingredient in most infant gas drops. 95% of the group treated with the probiotics were noted to respond with significantly less crying within 7 days. Only 7% of the simethicone group showed a similar response.

So what is it about probiotics that could potentially make some miserable babies at ease? Inflammation can trigger painful dysmotility or spasm of the intestinal tract. The well-known anti-inflammatory properties of probiotics could be countering the allergic effects of proteins encountered by these babies. It’s possible that a natural imbalance of intestinal flora could explain the misery of some babies. And L. reuteri has been shown to inhibit visceral pain which may explain why babies may feel better but doesn’t explain why they were in pain to begin with. All of this, of course, may be irrelevant to a mother working on 4 hours of sleep.

Irrespective of why the babies in this study felt better, the results are thought provoking and leave us with as many questions as answers. Structuring studies that deal with slippery topics like colic is tricky business. More placebo-controlled studies will help define the role of probiotics in treating screaming babies.

L. reuteri is available in infant drops through Biogaia, a Swedish biotechnology interest that produces probiotics for companies manufacturing functional foods.